Revised 1/08/2020
TOWN OF LAKE CLARKE SHORES
1701 BARBADOS ROAD
LAKE CLARKE SHORES FL
33406 (561) 964-1515 EXT. 1114
BUILDING PERMIT APPLICATION
Application is hereby made for a permit to erect/alter a structure as described herein or shown in accompanying plans and
specifications, which structure is to be located as shown on the plot plan. The following information and the accompanying
plans and specifications with the representations contained therein are made a part of this application in reliance upon which
the Building Official is requested to issue a building permit. It is understood and agreed by applicant that any error,
misstatement or misrepresentation or expression of fact, either with or without intention on the part of applicant, such as
might or would operate to cause a refusal of this application, or any material alteration or change in the accompanying plans,
specifications or structure made subsequent to the issuance of a permit in accordance with this application, without the
approval of the Building Official, shall constitute sufficient ground for the revocation of the permit. In consideration of granting
this permit, applicant agrees; (1) To install approaches, turnouts, driveways, and aprons at such elevations as established by
the engineer; (2) To cause all lots to be surveyed and staked prior to commencement to any construction; (3) To provide
adequate sanitary toilet facilities for workmen prior to the commencement of any construction; (4) To complete the
erection/alteration in accordance with the plans and specifications, the representations contained herein, and the Building,
Plumbing , and Electrical Code and other applicable requirements; (5) To comply with provisions of the Florida of the date
of issuance. No structure shall be occupied prior to the issuance of a Certificate of Occupancy, which shall be issued upon
request after the final inspection by the Building Official.
WARNING TO OWNER:
FAILURE TO RECORD A NOTICE OF COMMENCEMENT AND SUBMIT A COPY WITH THE PERMIT APPLICATION
PRIOR TO PERMIT ISSUANCE MAY RESULT IN YOUR PAYING TWICE FOR IMPROVEMENTS TO YOUR PROPERTY.
Address of Job:
Owner:
Contractor: Address:
Engineer/Architect: Phone Number:
Description of Work:
Date of Application: Value: $
No
te: The permit issued will be void after 180 days, unless the work that it covers has been commenced. All
contractors must have a valid business tax receipt for their business location, state or county certificate of
competency and proof of insurances prior to obtaining permits. Drawings, specifications, plot plans, etc. must be
provided in duplicate when submitting application.
ISSUANCE OF A PERMIT DOES NOT AUTHORIZE VIOLATION OF DEED RESTRICTIONS
Application is hereby made to obtain a permit to do the work and installations as indicated. I certify that no work or installation
has commenced prior to the approved permit being posted on the job site and that all work will be performed to meet the
standards of all laws regulating construction in this jurisdiction.
The undersigned hereby certifies that the above information is true and correct.
Signature of Qualifier Print name Phone
Permit Service Company (if applicable) Phone
S
tate of Florida (Notary required if signed outside of Town Hall Office)
County of
The foregoing instrument was sworn to (or affirmed), subscribed, and acknowledged before me by means of physical
presence or online notarization, this day of , 20 , by ,
who is personally known to me or has produced as identification.
Seal:
Notary Public-State of Florida at Large
OFFICE US
E ONLY:
Permit Fee $ State Surcharge $ Plan Review $ Total $
Check No. Credit Cash Date Paid Receipt No.
BUILDING OFFICIAL USE ONLY:
Permit No. Issued Approved by Date
